elon}
Today’s Date: ____________________
PERSONAL INFORMATION
Please Check One: ____Student ____Faculty/Staff ____ Affiliate ____Spouse-Student ____Spouse-Faculty/Staff
Please Check One: ____Dr. ____Rev ____Mr. ____Mrs. ____Ms.
Name:_____________________________________________ _____Male _____Female
Date of Birth:______________________________ Datatel #:___________________________
Address:________________________________ City:_______________ State:_______ Zip:____________
Day Phone: (_____)____________ Evening Phone: (_____)_________ Cell Phone: (_____)___________
Email address:______________________________ How frequently do you check email?________________
Emergency Contact:________________________________ Relationship:__________________________
Emergency Contact Phone: (______)__________¬¬¬_________
TRAINING INFORMATION
What personal training service are you purchasing?
_____Single Session A _____Single Session B _____Faculty/Staff PWU Session
_____3 _____6 _____13 _____21 _____29
_____Tag Team 6 _____Tag Team 10 _____Tag Team 12
When is the best time to contact you by phone?_________________________________________________
When would you like to begin your personal training program?____________________________________
What day(s) and time(s) are you looking to schedule your personal training sessions?____________________
________________________________________________________________________________________
Trainer Preference: _____Male Trainer _____Female Trainer _____No Preference
Is there a particular trainer with whom you would like to work with?__________________________________
Additional Comments:______________________________________________________________________
How did you hear about the Personal Training Program: ___Website ___Pendulum ___Friend
___ Fitness Center ___Other:______________________
PHYSICAL ACTIVITY
1. Height:__________ Weight:__________
2. In the past year, how often have you engaged in physical activity?
_____Regularly (3-4 times/week) _____Semi regularly (1-2 times/week)
_____Sporadic (1 to 2 times/month) _____None
3. What are your personal barriers for not exercising or sticking to a program?_________________________
___________________________________________________________________________________
4. How much time do you plan on spending on your workout program?
_____Minutes/Day _____Day/Week
EXPECTATIONS
1. Why have you decided to begin or improve your exercise program?_______________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
2. Why have you decided to hire a personal trainer?
• Need motivation and accountability
• Improve physical fitness
• Weight loss
• Improve strength
• Boredom with current workout
• Want to learn more about fitness
• Other?____________________________
3. Specifically describe what you would like to accomplish in your personal training sessions? ___________________________________________________________________________________ ___________________________________________________________________________________
4. Specifically describe what you would like to accomplish through your fitness program during the next:
• 1 month:______________________________________________________________________
• 4 months:______________________________________________________________________
• 1 year:________________________________________________________________________
MEDICAL INFORMATION
Please indicate whether you CURRENTLY HAVE or PREVIOULSY HAVE HAD a significant problem with any of the symptoms or conditions listed below:
Condition Yes No Don’t Know Comments
Unexplained weight loss or gain
Chronic fatigue
Change in appetite
Cancer
Chest pain or pressure
Chest pain with exertion
Heart attack
Rapid or irregular heart beats
Fainting, dizziness, or lightheadedness
High blood pressure
Stroke
High blood cholesterol
High blood triglycerides
Diabetes
Hypoglycemia/Low blood sugar
Asthma
Unexplained shortness of breath during physical activity
Chronic joint or muscle pain
Back pain
Arthritis or Rheumatic condition
Bone, joint, or muscular injury
Surgical procedures
Thyroid disease
Epilepsy
Eating disorder
Persistent Headache
Bursitis
Please list any additional medical concerns/conditions that might limit your ability to participate in this program (pregnancy, disability, recent surgery, etc): ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list current medications including overt-the counter medications, prescriptions, etc.
Medication Dosage Reason for Taking
Known Allergies (Environmental, Medications, Food, etc.): _________________________________________________________________________________________________
FAMILY MEDICAL HISTORY
Please indicate if any family member has had any of the following:
Medical Condition Relationship Comments
Heart attack
Stroke
Cardiovascular disease
High blood pressure
High cholesterol
Diabetes
Obesity
Cancer
Osteoporosis
Other